A Missed Opportunity to Cultivate Positive Attitudes about Mental Health Recovery among Undergraduate Nursing Students - A Quasi-Experimental Controlled Study.

INTRODUCTION: Mental health recovery is a critical concept that needs to be thoroughly understood and supported by nurses. Undergraduate nurse educators have the opportunity to clarify misconceptions and cultivate positive recovery attitudes. AIM: To assess the impact of an undergraduate nursing course on attitudes toward mental health recovery and the relationship between recovery attitudes and prejudice toward those who experience a mental illness. METHODS: A quasi-experimental pretest-posttest, nonequivalent-control group study was conducted using a sample of undergraduate nursing students in New York City (N = 126). The intervention group was assigned to an undergraduate mental health nursing course and the control group to a pediatric/maternal health nursing course. Attitudes toward mental health recovery and prejudice were measured at the beginning and end of the semester. Two-way mixed analyses of variance were used to determine the differences in students' attitudes. Pearson product-moment correlation analyses were used to assess the relationship between prejudice toward people who experience a mental illness and attitudes toward recovery. RESULTS: The mental health nursing course had no measurable impact on students' recovery attitudes. However, there was a moderate-to-strong inverse relationship between recovery attitudes and prejudice toward those who experience a general mental illness (r = -0.54), depression (r = -0.60), or schizophrenia (r = -0.43). CONCLUSIONS: Curriculum reform is needed to optimize the impact of undergraduate education on students' attitudes. Possible changes include a more holistic approach to mental health that does not over accentuate the biomedical model, the use of nontraditional clinical sites that provide students an opportunity to interact with those further along in their recovery, and the inclusion of those in recovery in curriculum development. As there was a moderate-to-strong inverse relationship between recovery attitudes and prejudice, educational interventions that positively impact one may also impact the other. Further research is needed to investigate if the relationship is causal.

A Systematic Review of the Application of Simulation to Promote Empathy in Nursing Education.

SUMMARY STATEMENT: This systematic review aimed to identify, appraise, and synthesize evidence for the effectiveness of simulation modalities in promoting nursing students' empathy. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis was followed with 20 studies included. The Medical Education Research Study Quality Instrument (MERSQI) was used to evaluate the quality of the publications. The mean MERSQI score was 10.95 with an SD of 1.62, which was above the average in the literature.Five simulation modalities were identified: standardized patient, simulated suit, manikin, virtual simulation, and virtual reality simulation. Most of the studies (n = 15) reported significant differences in the measured outcomes after their simulation activities, including all 5 simulation modalities, but the most effective modality was the simulation suit. The simulation suit replicates the lived experiences of others, which enhances perspective taking by "turning the student into the patient" through the physical and sensory effects of simulated suits. However, outcome measures were limited to self-report instruments in the studies.

The Effects of Mindfulness Meditation on Nursing Students' Stress and Anxiety Levels.

AIM: The aim of this study was to evaluate the effects of a virtual mindfulness meditation intervention on stress and anxiety levels of 145 nursing students. BACKGROUND: Because of the twin demands of classroom and clinical workloads, nursing students experience greater amounts of stress and anxiety than the average college student. Mindfulness meditation is a promising method to alleviate stress and anxiety. METHOD: A pretest-posttest randomized controlled design was used. Participants received either weekly mindfulness meditation recordings or recordings on nursing information. Participants completed the Perceived Stress Scale and the Generalized Anxiety Disorder-7 Scale. RESULTS: A two-way mixed analysis of variance and follow-up simple main effects tests revealed that participants in the experimental group, who received meditation recordings, experienced significantly lower levels of stress and anxiety on posttest surveys than the control group. CONCLUSION: Mindfulness meditation can reduce stress and anxiety levels in nursing students. This can improve students' overall mental and physical well-being.

When Did They Start? Age of Onset of Toileting Behaviors and Urinary Cues as Reported by Older Women.

Background: Lower urinary tract symptoms (LUTS) are prevalent across women's life course. Evidence shows toileting behaviors (TBs) and urinary urge cues are related to LUTS. It is unknown when women start using these behaviors and responding to urinary cues. Methods: An online survey was administered to 338 women, 65 years of age and older, to assess the age of onset for 20 TBs from the Toileting Behaviors-Women's Elimination Behavior (TB-WEB) questionnaire, 10 urinary urge cues from the Urinary Cues Questionnaire, and urinary urgency and leakage items from the International Consultation on Incontinence Questionnaire-Overactive Bladder (ICIQ-OAB) Short Form. Descriptive statistics were reported for each TB and urinary cue. A timeline was generated with the average earliest age of onsets for each type of TB, urinary cues, and urinary urgency and leakage symptoms. Results: Place preference, delayed voiding, and hovering over toilets away from home were reported to have the earliest ages of onset. Urinary urge cues, premature voiding, and straining to void tended to start after 45 years of age, as did the symptoms of urinary urgency and leakage. The timeline indicated that the earliest place preference and position preference TBs started before 20 years of age. Conclusion: Some TBs begin early in life and persist into old age, while other TBs and urinary cues begin later. Bladder health promotion may depend on intervening at specific times in the life course to alter TBs and responses, and potentially making environmental changes.

Using Meditation to Reduce Stress, Anxiety, and Depression in Nursing Students.

BACKGROUND: Nursing students experience higher rates of mental health issues than other college students. This study examined the effect of a mindfulness meditation intervention on nursing students' levels of self-reported depression, stress, and anxiety. METHOD: This randomized, experimental study implemented an online mindfulness meditation intervention for an experimental group of nursing students and provided nursing news modules for a control group of nursing students. Participants in experimental and control groups completed the Depression, Anxiety, and Stress Scale online before and after completing 4 weeks of audio modules. RESULTS: Results showed a statistically significant decrease in reported scores for depression, stress, and anxiety in the experimental group. CONCLUSION: This study demonstrated the potential benefits of implementing an online mindfulness meditation intervention to support and improve mental health for nursing students. [J Nurs Educ. 2023;62(8):443-449.].

Estrogen and Androgen Receptor Status in Uterosacral Ligaments of Women with Pelvic Organ Prolapse Stratified by the Pelvic Organ Prolapse Histology Quantification System.

Menopause is a significant risk factor for pelvic organ prolapse (POP), suggesting that ovarian sex steroids play a major role in the etiology of the condition. POP results from failure of the uterine-cervix-vagina support structures, including the uterosacral ligament (USL). We previously identified consistent degenerative USL phenotypes that occur in POP and used their characteristics to develop a standardized POP Histologic Quantification System (POP-HQ). In this study, POP and matched control USL tissue was first segregated into the unique POP-HQ phenotypes, and specimens were then compared for estrogen receptor (ER) alpha (ERα), ERbeta (ERß), the G-protein estrogen receptor (GPER), and androgen receptor (AR) content via immunohistochemical staining. ER and AR expression levels in the control USL tissues were indistinguishable from those observed in the POP-A phenotype, and partially overlapped with those of the POP-I phenotype. However, control-USL steroid receptor expression was statistically distinct from the POP-V phenotype. This difference was driven mainly by the increased expression of GPER and AR in smooth muscle, connective tissue, and endothelial cells, and increased expression of ERα in connective tissue. These findings support a multifactorial etiology for POP involving steroid signaling that contributes to altered smooth muscle, vasculature, and connective tissue content in the USL. Furthermore, these data support the concept that there are consistent and distinct degenerative processes that lead to POP and suggest that personalized approaches are needed that target specific cell and tissues in the pelvic floor to treat or prevent this complex condition.

Acknowledging Stigma: Levels of Prejudice among Undergraduate Nursing Students toward People Living with a Mental Illness-A Quasi-Experimental Single-Group Study.

INTRODUCTION: The undergraduate mental health nursing course may be an optimal time to cultivate students' positive attitudes toward people living with a mental illness. AIM: To determine the impact of an undergraduate mental health nursing course on students' attitudes toward people living with a mental illness, depression, and schizophrenia. METHOD: A quasi-experimental single-group pretest posttest study was conducted using a sample of undergraduate nursing students in New York City (N = 44). Self-reported measures of prejudice toward those living with a mental illness were collected at the beginning of a mental health nursing course and again at its conclusion. RESULTS: A statistically significant decrease in prejudice scores was found concerning mental illness (p = .03, d = 0.23), depression (p = .01, d = 0.31), and schizophrenia (p = .013, d = 0.34). Subscale analysis revealed significant decreases in the fear/avoidance and unpredictability subscales. Yet no significant change was found in the subscales of authoritarianism and malevolence for any of the three conditions. DISCUSSION: A mental health course led to a modest decrease in prejudice. However, certain facets of prejudice remain unchanged. IMPLICATIONS FOR PRACTICE: Major curricular reform is needed to optimize the impact of undergraduate nursing education.

Toileting behaviors, urinary cues, overactive bladder, and urinary incontinence in older women.

INTRODUCTION AND HYPOTHESIS: Overactive bladder (OAB) and urinary incontinence (UI) are prevalent in older women. We investigated relations of toileting behaviors and urinary urge cues to OAB and UI in women ≥ 65 years. We tested mediation hypotheses that toileting behaviors lead to higher sensitivity to urinary urge cues (the mediator), which leads to both OAB and UI. METHODS: An e-panel was recruited to respond to an electronic survey that included demographic information, Urinary Cues Scale version 2, Toileting Behaviors-Women's Elimination Behaviors (TB-WEB) scale, and the International Consultation on Incontinence Questionnaire Short Forms for Urinary Incontinence (ICIQ-SF-UI) and Overactive Bladder (ICIQ-SF-OAB). Descriptive statistics were conducted; correlation matrices were created to explore relationships among major variables. Regression analyses were conducted to test our mediation hypotheses. RESULTS: There were 338 respondents with average age 70.9 (SD + 5.55) years. Most were white, overweight or obese, and had UI. Urinary urge cues fully mediated the relationship of TB-WEB with OAB. Urinary urge cues partially mediated the relationship of TB-WEB with UI; the direct effect of toileting behaviors on UI remained significant. Age and body mass index had significant partial correlations with UI but not with OAB. DISCUSSION: Toileting behaviors appear to contribute to sensitivity to urinary cues, which are related to both OAB and UI. Toileting behaviors have indirect effects on OAB and both indirect and direct effects on UI. Interventions to change toileting behaviors and extinguish urinary cues are needed. CONCLUSIONS: Behavioral and conditioning factors contribute to UI in older women.

Obstetric anal sphincter injuries and other delivery trauma: a US national survey of obstetrician-gynecologists.

INTRODUCTION AND HYPOTHESIS: Obstetric lacerations complicate the majority of deliveries. The application of standardized guidelines for assessing delivery trauma has not been assessed thoroughly in the United States. We recently identified gaps in US midwives' clinical assessment of delivery trauma. We conducted a cross-sectional national survey of practicing obstetricians in the USA to characterize their classification of obstetric lacerations. We hypothesized that attending obstetricians' identification and diagnosis of delivery trauma would be similar to our findings for midwives with frequent inaccuracy. METHODS: We recruited clinically active obstetricians through the Pregnancy-Related Care Research Network. We asked participants to classify (from written definitions) and diagnose (from standard illustrations) common forms of vaginal delivery trauma using the widely employed perineal laceration degree system. We performed bivariate analysis of high- and low-scoring respondents and logistic regression to model characteristics associated with higher diagnostic accuracy. RESULTS: Of the 162 respondents who started the survey, 76% (123) were included for analysis (22% of solicited emails). Overall, we found wide variation in response accuracy with as few as 62% of respondents correctly classifying certain types of lacerations. Only 49 out of 123 (40%) use the Sultan third-degree subclassification system and 67 out of 123 (52%) continue to use the midline/median approach for episiotomies. Providers reporting fewer deliveries per month and fewer publicly insured patients earned higher scores. CONCLUSIONS: Obstetricians in a nationally representative US perinatal provider network inconsistently identify perineal and nonperineal lacerations. We found important clinical knowledge gaps, suggesting that vaginal delivery diagnoses in obstetric quality studies and pelvic floor research might be inaccurate.

Accuracy of obstetric laceration diagnoses in the electronic medical record.

INTRODUCTION AND HYPOTHESIS: Patient safety data including rates of obstetric anal sphincter injury (OASI) are often derived from hospital discharge codes. With the transition to electronic medical records (EMRs), we hypothesized that electronic provider-entered delivery data would more accurately document obstetric perineal injury than traditional billing/diagnostic codes. METHODS: We evaluated the accuracy of perineal laceration diagnoses after singleton vaginal deliveries during one calendar year at an American tertiary academic medical center. We reviewed the entire hospital chart to determine the most likely laceration diagnosis and compared that expert review diagnosis (ExpRD) with documentation in the EMR delivery summary (EDS) and ICD-9 diagnostic codes (IDCs). RESULTS: We retrospectively selected 354 total delivery records. OASI complicated 56 of those. 303 records (86%) were coded identically by the EDS and IDCs. Diagnoses from the IDCs and the EDS were mostly correct compared with ExpRD (sensitivity = 96%, specificity = 100%). There was no systematic over- or under-diagnosis of OASI for either the EDS (p = 0.070) or the IDCs (p = 0.447). When considering all laceration types the EDS was correct for 21 (5.9%) lacerations that were incorrect according to the IDCs. Overall, the EDS was more accurate (p < 0.05) owing to errors in IDC minor laceration diagnoses. CONCLUSIONS: Electronic medical record delivery summary data and EMR-derived diagnostic codes similarly characterize OASI. The EDS does not improve OASI reporting, but may be more accurate when considering all perineal lacerations. This assumes that providers have correctly identified and categorized the lacerations that they record in the EMR.

Using the novel pelvic organ prolapse histologic quantification system to identify phenotypes in uterosacral ligaments in women with pelvic organ prolapse.

BACKGROUND: Pelvic organ prolapse is common, but the underlying etiologies are poorly understood, which limits our current prevention and treatment options. OBJECTIVE: Our primary objective was to compare the uterosacral ligament histologic features in women with and without prolapse using the novel pelvic organ prolapse histologic quantification system. Our secondary aim was to determine whether composite histologic findings in uterosacral ligaments are associated with prolapse risk factors. STUDY DESIGN: This was a prospective cohort study in which paracervical uterosacral ligament biopsies were performed at the time of hysterectomy for primary prolapse or other benign gynecologic indications and processed for histologic evaluation. The pelvic organ prolapse quantification system was used to determine the prolapse stage. In this study, 9 prominent histologic features were semiquantitatively scored using the pelvic organ prolapse histologic quantification system in a blinded fashion and compared between prolapse and control groups. Unbiased principal component analysis of these scores was independently performed to identify potential relationships between histologic measures and prolapse risk factors. RESULTS: The histologic scores of 81 prolapse and 33 control ligaments were analyzed. Compared with the control group, women in the prolapse group were significantly older and more likely to be in the menopausal phase. There was no difference in the number of vaginal deliveries, body mass index, hormone use, or smoking status between the groups. To control for baseline differences, patients were also stratified by age over 40 years and menopausal status. Compared with the control group, the prolapse ligaments in the premenopausal group had significantly more loss of smooth muscle fibers within the fascicles (P<.001), increased inflammatory infiltrates of neutrophils within the tissue and perineural inflammatory cells (P<.01 and P=.04, respectively), and reduced neointimal hyperplasia (P=.02). Prolapse ligaments in the postmenopausal group exhibited elevated adipose content compared with that of the control group (P=.05). Amount of fibrillar collagen, total nonvascular smooth muscle, and muscle fiber vesicles of prolapse ligaments did not differ in either the premenopausal or postmenopausal group compared with that of the control group. Unbiased principal component analysis of the histologic scores separated the prolapse ligaments into 3 phenotypes: (1) increased adipose accumulation, (2) increased inflammation, and (3) abnormal vasculature, with variable overlap with controls. Posthoc analysis of these subgroups demonstrated a positive correlation between increasing number of vaginal deliveries and body mass index with increasing adipose content in the adipocyte accumulation and inflammatory phenotype and increasing neointimal hyperplasia in the vascular phenotype. However, only the relationship between vaginal delivery and adipocytes was significant in the adipose phenotype (R2=0.13; P=.04). CONCLUSION: Histologic phenotypes exist in pelvic support ligaments that can be distinguished using the pelvic organ prolapse histologic quantification system and principle component analysis. Vaginal delivery is associated with aberrant adipose accumulation in uterosacral ligaments. Our findings support a multifactorial etiology for pelvic organ prolapse contributing to altered smooth muscle, vasculature, and connective tissue content in crucial pelvic support structures. To confirm these associations and evaluate the biomechanical properties of histologic phenotypes of prolapse, larger studies are warranted. Closing this gap in knowledge will help optimize personalized medicine and help identify targets for prevention and treatment of this complex condition.

Identification of obstetric anal sphincter injuries (OASIs) and other lacerations: a national survey of nurse-midwives.

INTRODUCTION AND HYPOTHESIS: Clinical quality improvement relies on accurate understanding of current practice. We performed a cross-sectional national survey of certified nurse-midwives (CNMs) assessing classification and identification of obstetric anal sphincter injury (OASI) and other delivery lacerations. We hypothesized laceration diagnoses are frequently inaccurate, and delivery records for obstetric lacerations may be of questionable quality. METHODS: We emailed 6909 American College of Nurse Midwives members an internet-based survey link. Of respondents, we included clinically active CNMs who perform at least one delivery per month. We evaluated laceration knowledge and application using standard descriptive text and images and asked about processes for recording lacerations in the delivery record. RESULTS: We received 1070 (15.5%) completed surveys and 832 (77.8%) met inclusion criteria. Over 50% characterized their OASI training and ability to identify OASI as good/excellent. Most (79%) had never attended education review on OASI. The overall accuracy for classification and identification of perineal lacerations ranged from 49 to 99%. Non-perineal lacerations were frequently categorized using the perineal/OASI system. Half of respondents (51%) document their deliveries in an electronic medical record but a quarter (28%) are not personally responsible for approving delivery data. Younger participants without a doctoral degree, with self-assessed good/excellent laceration training, and caring for < 50% publicly insured patients had higher accuracy for laceration identification and diagnosis. CONCLUSIONS: We found high rates of inaccurate laceration diagnosis and inappropriate application of the perineal OASI degree system, suggesting education and training are needed. Clinical studies that rely on delivery diagnosis of OASI may not be reliable.

Experimental and Quasi-Experimental Studies of Teaching Methods in Nursing Education, 1972-2017.

Review of 145 experimental and quasi-experimental studies of teaching strategies in nursing education revealed that 52 percent were published outside the United States, 80 percent with undergraduate students. Seventy-seven percent assessed learning outcomes, and 80 percent had statistically significant findings. A surge in studies since 2010 showed no increase in methodological rigor. Two thirds had sample sizes less than 100, 77 percent were quasi-experimental, and 23 percent were one-group designs. Few authors published more than one experimental study of teaching methods. Findings underscore the need for more sophisticated methods and more funding for nursing education research.

Prevention and Management of Severe Obstetric Anal Sphincter Injuries (OASIs): a National Survey of Nurse- Midwives.

INTRODUCTION AND HYPOTHESIS: There are no data on midwives' knowledge and management of obstetric anal sphincter injuries (OASIs) in the USA. We performed a cross-sectional national survey characterizing OASI practice by certified nurse midwives (CNMs), hypothesizing that few midwives personally repair OASIs and that there are gaps in CNM OASI training/education. METHODS: We emailed a REDCap internet-based survey to 6909 American College of Nurse Midwives members (ACNM). We analyzed responses from active clinicians performing at least one delivery per month, asking about OASI risks, prevention, repair, and management. We summarized descriptive data then evaluated OASI knowledge by patient and provider characteristics. RESULTS: We received 1070 (15.5%) completed surveys, and 832 (77.8%) met the inclusion/exclusion criteria. Participants were similar to ACNM membership. Respondents most frequently identified prior OASI (87%) and nutrition (71%) as antepartum OASI risk factors and, less frequently, nulliparity (36%) and race (22%). Identified intrapartum risks included forceps delivery (94%) and midline episiotomy (88%). When obstetric laceration is suspected, 13.6% of respondents perform a rectal examination routinely. Only 15% of participants personally perform OASI repair. Overall, participants matched 64% of evidence-based answers. OASI education/training courses were attended by 30% of respondents, and 44% knew of OASI protocols within their group/institution. Of all factors evaluated, the percent of evidence-based responses was only different for respondent education/CME and protocols. CONCLUSIONS: Quality initiatives regarding OASI prevention and management may improve care. Our data suggest OASI training for midwives may improve delivery care in the US. Further studies of other obstetric providers are needed.

Relationship of cue-induced urinary urges to nocturia in women ages 18 to 40 years.

AIMS: Although physiological factors have a role in nocturia, research suggests that behavioral processes, especially classical conditioning may also play an important role in nocturia and other lower urinary tract symptoms. The study aimed to assess the relationship of stimulus-associated urges during the day to nocturia in a sample of women aged 18 to 40, after controlling for physiological symptoms (eg, overactive bladder [OAB]; daytime frequency). METHODS: An online study was conducted using a panel of 356 female participants between the ages of 18 to 40. One-third of the participants self-reported an OAB diagnosis as determined by their physician. Almost 80% of participants reported having at least one nocturnal voiding per night. Participants completed the Urinary Cues Questionnaire, which assessed the frequency with which respondents experienced the urge to urinate in the presence of a variety of cues and the Overactive Bladder Screening Scale (OABSS), which assesses symptoms of OAB syndrome. RESULTS: Controlling for OABSS scores and daytime urinary frequency, the Situational Cues Subscale had a significant relationship with nocturia such that with each unit increase in the subscale, the probability of nocturia increased by 12% to 14% depending on the definition of nocturia. DISCUSSION: Behavioral techniques, such as habituation to decrease the association between awakening at night and feeling an urge to urinate, may be an appropriate intervention to mitigate nocturnal urination. Theoretically, this would translate to decreasing this disorder throughout the lifespan, if behavioral techniques could be effectively utilized in early adulthood.